Physician Assisted Suicide: A New Global Trend, or a Far Stretch for Policymakers?

On September 11, the California State Legislature, by a vote of 23 to 14, approved a bill that would allow the practice of physician assisted suicide in the state. If the bill gains the approval of Governor Jerry Brown, California would become the fifth state, alongside Oregon, Washington, Montana, and Vermont, to offer terminally ill patients the option of assisted suicide at the end of life.1 The New York Times article announcing the bill’s approval cited that many other states—more than half, in fact—have put forward bills for the legalization of assisted suicide.

Logo for the nonprofit organization, Dying with DignitySA. Source: commons.wikimedia.org

The practice of physician-assisted suicide was first legalized in Oregon in 1997, and now, with increasing amounts of pressure from humanitarian groups, other states are ready to join the movement for greater autonomy at the end of life.1 Research on the implementation of the Death with Dignity Program at the Seattle Cancer Care Alliance generally found a positive reaction to the program. They found that of the 114 patients who inquired about the program from March 2009 to December 2011, 24 patients received and took a lethal prescription, after much counsel with physicians. In this study, all of those receiving a lethal prescription suffered from cancer. Their primary reasons for choosing assisted suicide were a loss of autonomy, inability to engage in enjoyable activities, and a loss of dignity.2

Humanitarian groups around the world share these concerns about terminally ill patients’ loss of autonomy and dignity. In high-income countries in which euthanasia is illegal, there is a push for the ability to choose at the end of life. The group Dying with DignitySA, a nonprofit launched in South Africa in 2011, asserts, “A lack of assisted-dying legislation makes criminals out of noncriminals.”3 They seek to gain enough momentum to effect change and pass laws in South Africa allowing the possibility of assisted suicide. It seems that part of their goal is to prevent terminally ill patients from taking their own lives in ways other than physician-assisted suicide, as they cite the distress such attempts can cause for families as well as the consequences of failed attempts.3

Another group, Dignitas, goes beyond policy advocacy and makes a profound difference in the lives of terminally ill patients. Based in Switzerland, Dignitas describes itself as a non-profit advocating for self-determination, autonomy, and dignity.4 They take a similar stance to that of Dying with DignitySA in that they seek to prevent suicide attempt, while simultaneously supporting people’s right to a dignified death. They are clear in their purpose—they are in no way supporting the euthanizing of physically and mentally healthy people. Rather, they are a group that offers counseling on issues related to end of life, but also offers the possibility of an accompanied suicide. Dignitas states that their objective is first to show terminally ill patients “a way to continue living.” Yet they value attempts to alleviate inhumane suffering, while upholding the freedom and autonomy of the individual.4

Map of the global status of euthanasia. Source: commons.wikimedia.org

British Parliament’s rejection of an assisted suicide bill earlier this month indicates that many see the legalization of assisted-suicide as the validation or acceptance of a tragedy. It does not seem that views are likely to change any time soon. In 1997, 72% of Members of Parliament were opposed to legalization of assisted suicide. Now, 18 years later, views have stayed constant, with 74% of Members of Parliament rejecting the bill, despite overwhelming public support for such a bill.5 The law proposed to Parliament earlier this month would have allowed the prescription of lethal medication to terminally ill patients with less than six months to live. Members of Parliament, however, pointed to the difficulty in determining length of life left, in addition to the ethics of “killing” the same vulnerable people that the government is obliged to protect.5

Seattle Cancer Care Alliance. Source: commons.wikimedia.org

In existing assisted suicide programs, there are safeguards to ensure that those who inquire about assisted suicide have carefully considered their options. Dignitas, for example, seeks to counsel, not to coerce.4 In the Death with Dignity program at the Seattle Cancer Care Alliance, patients must make both an initial oral and written request and another oral request 15 days later. Doctors assess the patient’s diagnosis and competency and give the patients the option to rescind the request when prescribing the medication.2 Despite these safeguards, however, concerns remain about the ethics of this procedure.

It would have been difficult to imagine this debate one hundred years ago, when people died of communicable diseases at much younger ages. With increasing life expectancy, however, people now live with disability and disease for many years, experiencing pain and losing autonomy. It remains unclear as to whether death with dignity programs will continue to be legalized on state or national levels. Ethics of such programs aside, there is a need for palliative care and public health efforts to delay the onset of morbidity. Perhaps this may be another avenue by which to ensure the dignity of elderly throughout the world.